Patient: R.C.

Chief Complaints: Body weakness Assessment Actual/ Abnormal cues

Functional

Age: 90 years old

Gender: Female Admitting Diagnosis: Electrolyte Imbalance secondary to Poor intake

Level Classification: 3 (Requires help from another person and equipment device) Muscle strength of 3/5 score (muscle can contract and can move the body part fully against gravity but with limitations) Assisted with hourly turning to different

Nursing Diagnosis Impaired physical mobility of the upper and lower extremities r/t neuromuscular skeletal impairment as evidence by limitation in moving, decrease muscle strength, and assisted when turning and moving. Definition: Limitation in independent, purposeful physical movement of the body or of one or more extremities

Rationale Precipitating Factors: -(+) Diabetes Mellitus -Poor Intake of foods with essential vitamins and minerals Predisposing Factors: - Age: 90 years old (Old Age) -Gender (postmenopaus al period)

Desired Outcomes After 3 days of nursing interventions, the patient will be able to: 1.)Demonstrate techniques or behaviors that enable resumption of activities

Nursing Interventions Independent and Collaborative Nursing Interventions

Justifications Independent and Collaborative Nursing Interventions

Evaluation After 3 days of nursing interventions, the patient was able to:

1.1 Assess degree of immobility produced by injury/treatment.

1.1 To initiate proper care and be able to assist in some part of the patients ADLs

Due to age related changes result to alteration of fast metabolism of micronutrients in the body plus low intake of foods rich in potassium

Low levels of circulating electrolyte to be disseminated to the different tissues and organs (esp. the brain)

1.2 Encourage participation in diversional/ recreational activities. Maintain stimulating environment, e.g., radio, TV, newspapers, personal possessions/pictures, clock, calendar, visits from family/friends. 1.3 Encourage use of isometric exercises starting with the unaffected limb.

1.2 Provides opportunity for release of energy, refocuses attention, enhances patients sense of self-control/selfworth, and aids in reducing social isolation.

Brain will be stimulated of the low levels of electrolyte (potassium)

1.3 Isometrics contract muscles without bending joints or moving limbs and help maintain muscle

positions. Facial mask of pain when turning the patient Weakness and limitation in motion of body parts Limited range of motion

Source: Doenges, M.E, et. Al. Nurses Pocket Guide Edition 11. F.A. Davis Company. Philadelphia, Pennsylvania. 2008.

Changes in the nerve impulse state leading to slow conduction of electrical signals from the central nervous system to its periphery 2.)Participate in ADLs and desired activities 2.1 Instruct patient in/assist with active/passive ROM exercises of affected and unaffected extremities.

strength and mass. Note: These exercises are contraindicated while acute bleeding/edema is present. 2.1 Increases blood flow to muscles and bone to improve muscle tone, maintain joint mobility; prevent contractures/atrophy and calcium resorption from disuse 2.2 Improves muscle strength and circulation, enhances patient control in situation, and promotes selfdirected wellness. 3.1 Useful in maintaining functional position of extremities, hands/feet, and preventing complications (e.g., contractures/footdrop). 3.2 Prevents/reduces incidence of skin and respiratory complications (e.g., decubitus, atelectasis, pneumonia). 3.3 Bed rest, use of analgesics, and changes in

Marked weakness of the extremities

Impaired physical mobility of the upper and lower extremities r/t neuromuscular skeletal impairment Source: Medical-Surgical Book Edition 16 by Williams and Wilkins.

2.2 Assist with/encourage self-care activities (e.g., bathing, shaving).

Strengths: Strong family support Good compliance to treatment and medications 3.) Maintain position of function and skin integrity as evidenced by absence of contractures, footdrop, decubitus, and so forth. 3.1 Provide footboard, wrist splints, trochanter/hand rolls as appropriate.

3.2 Reposition periodically every 2 hours and encourage coughing/deepbreathing exercises. 3.3 Auscultate bowel sounds. Monitor

elimination habits and provide for regular bowel routine. Place on bedside commode, if feasible, or use fracture pan. Provide privacy.

dietary habits can slow peristalsis and produce constipation. Nursing measures that facilitate elimination may prevent/limit complications. Fracture pan limits flexion of hips and lessens pressure on lumbar region/lower extremity cast. 3.4 Creates positive assurance in maintaining the quality of care and update the current status of the patient.

3.4 Work hand in hand with other allied health care team in maintaining patients treatment and functionality